Health policies for migrant populations in three European countries: England; Italy and Spain
Introduction
International migrants represent 3.1% of the world population. Most (75%) move to a country with a higher HDI (human development index) but with the same development level, and 40% move to a neighbouring country for geographical, linguistic and religious reasons [1]. Women represent around half (49.6%) of the migrants world wide [2]. In recent years migrant populations have increased considerably in Europe; this is creating a new demographic, social and economic reality in host countries. The estimated proportion of foreign citizens in the EU27 was 6.2% (30 million) [3] in 2008; 56.0% of which moved from another European country [4]. The three main countries of origin are Turkey (7.9%), Morocco (5.6%) and Romania (5.4%) [3]. Most foreign citizens (75%) live in Germany (7.3 million), Spain (5.3 million), United Kingdom (4.0 million), France (3.7 million) and Italy (3.4 million) [3]. The proportion of women was slightly above half 53.4% in 2005 [5]. The number of undocumented immigrants is not known, but it was estimated to be between 5 and 8 millions in 2005 (1–1.7% of the total population) [6].
The healthcare needs of the immigrant population change with time of residence in the host country: from problems relating to the country of origin and the immigration journey, they move on to adaptation related problems, finally converging on the health problems of the native population [7], [8]. Migrants, however, tend to be more exposed to certain risk factors and to be more susceptible to suffer from hypertension, chronic diseases, low birth weight, and obesity, among other pathologies [9].
Despite the fact that the migrant population's health needs are comparable to those of the local population, they are, however, manifestly more vulnerable [10]. On the one hand, it is a result of poorer health determinants, such as lower purchasing power or precarious living and working conditions [9], [11] that are even worse in the case of undocumented immigrants [12], [13]. On the other hand, it is a result of certain specific factors, such as language, culture, religion or simply not knowing how the system works. In the case of women, they add gender inequalities [2]. Both sets of factors can lead to unequal access or even to being excluded from health services altogether [10], [14].
The European Commission stresses the importance of ensuring that immigrants have access to health services under equal conditions to those of the local population in order to reduce inequalities in health and to eliminate discriminatory situations [15], [16], [17]. Consequently, host countries face the challenge of providing health care to a population with very specific characteristics, which may translate into new demands in the provision of care [15].
Health policies are an important determining factor of access to health care, as they can influence aspects of health services delivery such as the availability of resources, organization, financing; and aspects of the population itself, with specific programmes addressing features prone to be modified, for example, health knowledge and practices, insurance coverage or service information issues [18].
Two levels of health policy can be distinguished: the first is the legislative level where the health rights of immigrants are established, by means of laws and decrees; the second is the specific response to this legislation by the health system [19], [20]. Health policy development would be influenced, among other factors, by the country tradition in matters of immigration and its models of integration. Countries that have an assimilation model simply expect immigrants to use the health system without introducing any changes, while countries with multicultural or multiethnic models recognize the specific needs of immigrants and formulate specific strategies [20], [21], [22]. Countries with a longer tradition as receiving countries have formulated and reformulated their policies over time while countries where this phenomenon is more recent are in the process of formulating and implementing policies [11], [20], [23].
The scientific literature has barely tackled the issue of analysing health and health care policies developed for immigrant populations. Despite the progress made along these lines [16], [19], [24], [25], so far no specific framework for analysing the content of health policies for migrant populations has been developed. Such an analysis should enable the identification of useful elements for orienting the design of policies in order to reduce inequalities in access and to respond to the needs of this group.
The aim of this article, which presents partial results of a wider study [26], is to undertake a comparative analysis of health policies for immigrants across three European Union countries with different traditions in matters of immigration, namely England, Italy, and Spain.
Section snippets
Study design
A descriptive comparative study of health policies for immigrants was carried out by means of a content analysis. Walt et al.’s definition of health policy was adopted for this purpose: “courses of action (and inaction) that affect the set of institutions, organizations, services and funding arrangements of the health system” [27]. Following an initial exhaustive literature search with scant results the study was limited to those health policies that are enshrined in national and regional plans.
Results
The results of the policy analyses are presented here in accordance with the major dimensions of analysis. Differences and similarities between the countries have been emphasized and reference made as to whether they deal with regional policies or, as in the case of Italy, they were in prior plans to those in force.
Discussion
The selected countries all have national health systems that guarantee universal health access to their population, including documented immigrant population, but have nevertheless developed specific health policies too. This seems to indicate, on the one hand, that it is not enough to grant a right to health care but that in order to guarantee that right it is necessary to modify services so that access to quality care becomes a reality. This is particularly remarkable in the case of England
Conclusions
In conclusion, policy development has evolved in parallel with immigrant population growth. English and Spanish policies seem to be steered towards the more significant problems relating to health and health care of this population group that require attention; this differs from Italy, where even if equity remains a principle of the health system, policies addressing specific migrants or ethnic minority groups in current plans are scarce. Nevertheless, experiences such as the English one, where
Acknowledgements
Authors are grateful to Andrew Canessa for his support in writing the paper and Gemma Mas for her contributions to the last version of the paper. The research was financed by the Directorate of Planning and Evaluation, Catalonian Health Department.
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