Elsevier

Health Policy

Volume 120, Issue 4, April 2016, Pages 396-405
Health Policy

Was access to health care easy for immigrants in Spain? The perspectives of health personnel in Catalonia and Andalusia

https://doi.org/10.1016/j.healthpol.2016.01.011Get rights and content

Highlights

  • Empirical research on migrant's access to health care from health professional's perspective is limited in Europe.

  • Despite universal health coverage barriers to health care access are identified.

  • Complex interaction between health services’ and migrants individual’ characteristics affect access to health care.

  • To overcome barriers, policies should address healthcare services and immigrants’ characteristics.

  • Policies should also address other social determinants to avoid health inequalities.

Abstract

Until April 2012, all Spanish citizens were entitled to health care and policies had been developed at national and regional level to remove potential barriers of access, however, evidence suggested problems of access for immigrants. In order to identify factors affecting immigrants’ access to health care, we conducted a qualitative study based on individual interviews with healthcare managers (n = 27) and professionals (n = 65) in Catalonia and Andalusia, before the policy change that restricted access for some groups. A thematic analysis was carried out. Health professionals considered access to health care “easy” for immigrants and similar to access for autochthons in both regions. Clear barriers were identified to enter the health system (in obtaining the health card) and in using services, indicating a mismatch between the characteristics of services and those of immigrants. Results did not differ among regions, except for in Catalonia, where access to care was considered harder for users without a health card, due to the fees charged, and in general, because of the distance to primary health care in rural areas. In conclusion, despite the universal coverage granted by the Spanish healthcare system and developed health policies, a number of barriers in access emerged that would require implementing the existing policies. However, the measures taken in the context of the economic crisis are pointing in the opposite direction, towards maintaining or increasing barriers.

Introduction

In 2013, Spain had the second greatest foreign-born population in the European Union after Germany – with 5.1 million people – and ahead of the United Kingdom [1]. A decade of rapid and concentrated immigration, particularly in some regions – Catalonia, Madrid, Valencia and Andalusia [2] – changed the social make-up and presented a challenge for public services, including health services, which had to meet the needs of a more diverse population. Research in countries with historically high levels of immigration has revealed immigrants’ greater risk of exclusion from healthcare services [3], [4].

Existing evidence from different European countries highlights inequalities in immigrants’ access to health services [5], [6]. However, research identifying the factors that influence access to health care seems to be limited and there is even less research focusing on the perspectives of health workers themselves. Available studies analyse their difficulties in providing care to immigrants [7], [8], [9]. Regarding access, the research available to date has tended to focus on undocumented immigrants [10], [11], [12] and, only recently, some descriptive studies have included documented immigrants as well, with a focus on their perspectives [13], [14], [15]. Only one study has been identified that is based on a questionnaire survey amongst health personnel in Portugal [16]. These studies mention some potential barriers to access including service characteristics, but mainly focus on characteristics of the immigrants: low socio-economic status [16], limited knowledge of the local language and of healthcare entitlements.

In Spain, policies and laws evolved in tandem with the increase in immigration, and affected different aspects of foreigners’ lives, including their rights to health care and access to health services. Until 2012, when this was restricted, Spain's national health system guaranteed universal access to health care for all residents, regardless of their administrative status. In order for immigrants to exercise their right to health in the same conditions as that of the autochthonous, the only request was that they register at the city council. Those not registered were guaranteed only emergency care, with the exception of pregnant women and minors under the age of eighteen [17]. However, some studies have revealed inequalities in health between the autochthonous and immigrant populations that are not dependent on socio-economic status [18], [19], [20] and point to differences in accessing health care related to specific barriers, indicating that policies developed to address these barriers have not been fully implemented [21]. Moreover, access to health care might also differ by region: although entitlements to health care and social integration policies are defined by the central government, the national healthcare system is decentralized into 17 regional services. In this sense, differences in regional policy between Catalonia and Andalusia–where Non-Governmental Organizations (NGOs) directly provide immigrants with the healthcare card and there is reinforcement in program contracts – could translate into different results in immigrants’ access to health care [21], [22].

Recent reviews [23], [24] of immigrants’ access to health care in Spain reveal no clear patterns in the use of healthcare services and existing research has mainly explored trends in immigrants’ use of these services in comparison to autochthons. Studies analyzing the determinants of health services utilization are scarce and focus on individual factors (age, sex, level of education). The perspective of healthcare professionals has been captured through opinion surveys [25], [26] and qualitative studies [27], [28], [29], but these did not focus on immigrants’ access to health care, rather on health workers’ needs when providing care to immigrants.

In summary, there is limited empirical research available in Europe and particularly in Spain that analyzes immigrants’ access to health services and still less research has been conducted from the point of view of the healthcare professional. The objective of this article – which presents the partial results of a wider study [21], is to identify factors influencing immigrants’ access to health care from the perspective of health personnel in two Spanish regions.

Section snippets

Study design

A qualitative, descriptive and phenomenological study was conducted. The study population was health personnel that might have an opinion or influence on immigrants’ access to health care in Catalonia and Andalusia. Field work was carried out from April 2011 to March 2012, before the application of the new healthcare Act [30] which limited undocumented immigrants’ right to health care. The analysis is guided by Aday and Andersen's [31] theoretical framework of access that takes into account

Easy access to health care for immigrants in the National Health System (NHS)

The dominant opinion among all groups of informants from both regions was that access to health care was “easy” and “quick” for immigrants and equal in conditions to autochthons: they had equal access to the healthcare system “but…I don’t think it can be any harder for them [to access the health system]. I mean, they are given the same options, opportunities and…and in that sense…I don’t think there's any problem” (Professional Ru,SC,CAT), access to the same services and also to the same

Discussion

This study provides a systematic and comparative analysis regarding immigrants’ access to health care and the factors that influence it based on the perspective of healthcare professionals and managers in two Spanish regions. The study was conducted during the economic crisis, but before changes in the right to health care (entitlements) and the considerable reduction in public health expenditure had taken place. Access to health care in the national health system was generally considered easy

Conclusion

This study provides evidence that health personnel do identify barriers in access to health care, related to both the health services and to immigrants’ characteristics. Structural barriers were identified which must be addressed by specific policies, and they affect all users, both autochthons and immigrants, highlighting chronic deficiencies of the health system. However, these limitations of the healthcare system tend to affect the immigrant population more severely, due to their specific

Conflicts of interest

The authors declare that they do not have any conflict of interests.

Acknowledgements

To the Institut Català de la Salut, Serveis de Salut Integrats Baix Empordà, Hospital Parc de Salut Mar, Hospital d’Amposta i Verge de la Cinta de Tortosa and all the people who facilitated and made the field work possible. To the professionals who shared their time and opinions. To Rebeca Terraza, who conducted the fieldwork and initial analysis and to Emily Felt, Pamela and Kate Bartlett for the English version of the paper. This research was partially financed the Instituto de Salud Carlos

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