Health and undocumented immigrants: a social conundrum


Personal opinions and politics aside, the presence in Belgium of undocumented migrants raises the delicate question of their access to health care. Researchers at the UCL Institute of Health and Society are tackling it.

Between 85,000 and 160,000 people are in Belgium illegally. Questions raised by the presence of undocumented migrants are not new. Delicate and controversial, they trigger emotional responses, because they test our individual and collective values. ‘But no matter what you think, access to health care for undocumented migrants is first and foremost a public health issue’, says Dr Marie Dauvrin, a nurse, doctor of public health, and researcher at the UCL Institute of Health and Society. ‘Insufficient vaccination and complications related to untimely medical care has a cost for society—a financial but also a health and human cost. So it’s in the community’s interest to improve their access to health care.’ 

Emergency care and undocumented migrants

Keep in mind that asylum seekers and undocumented migrants are not equal when it comes to health care. Someone who officially requests asylum is under state protection and can thus benefit from primary health care services organised by his or her reception centre. But an undocumented migrant, by definition, has no administrative status; the only way to access health care is by requesting emergency medical care (EMC) at a Public Social Service Centre (CPAS).

In 2013, only 10% to 20% of undocumented migrants benefitted from EMC. ‘And yet any migration or immigration journey has an impact on your physical and/or mental health’, Dr Dauvrin explains. ‘The fact that so few undocumented migrants benefit from EMC or even dare to seek it clearly indicates there’s a problem.’ But what is it? This is what public authorities want to understand.


Disorder, inequality, lack of information

In late 2015, the Belgian Health Care Knowledge Centre (KCE) released a report1 on a field survey that aimed to understand the problem and propose solutions. KCE called on three researchers of the UCL Institute of Health and Society: Dr Dauvrin, Prof. Vincent Lorant and Research Assistant Julie Gysen.2

Their findings are clear: EMC access is hindered by a glaring lack of consistency in both legislation and practice. This leads to a lack of information, communication problems between the actors (undocumented migrants, social workers, the National Institute for Health and Disability Insurance or Institut national d'assurance maladie-invalidité (INAMI), the Federal Public Service for Finance (SPF), etc.) and, most important, poor health outcomes, some of them tragic. Caught up it in all: the Public Social Service Centres (CPASs).

Vague legal framework

The first subject of confusion is the legal framework. ‘The Royal Decree on EMC is vague and subject to interpretation’, says Dr Dauvrin, who co-authored the KCE report. ‘Even the notion of “emergency” isn’t clear. Are we talking about a medical or social emergency? In theory, EMC includes all care and services in the INAMI nomenclature. But in practice, every EMC action must be validated by a doctor who’s free to interpret the law as he wishes, or rather as he understands it. This is why EMC drugs and services aren’t the same from one CPAS to another.’

médicaments pillules

Inconsistent procedure

The EMC authorisation procedure is just as inconsistent. Theoretically, three conditions must be met to receive EMC:

  1. illegal residence;
  2. indigence;
  3. a need for health care (which must be confirmed by a doctor).

Thus the CPAS must inquire whether the applicant fulfils these three conditions. This ‘social inquiry’ is not always straightforward. What exactly is ‘indigence’? How do you prove a migrant is undocumented? Such are the questions left to CPAS social workers who, often overwhelmed with work, aren’t necessarily attuned to the system’s subtleties and jurisprudence. Which surely explains why the rate of EMC refusal varies from 2% to 26% among CPASs.

Practices differ

In addition, EMC is not practised the same way everywhere. ‘For example, some CPASs issue a health card that grants the user EMC for a fixed period’, Dr Dauvrin explains. ‘Others require an application, and thus an inquiry, for every requested service. In short, each CPAS works differently, which makes it harder to understand the system and discourages undocumented migrants from asking for the help to which they’re legally entitled.’

Potential solutions

All of the above translates into unequal access to health care. To reform the system, KCE report authors propose a series of measures:

  1. Replace the concept of ‘emergency’ with the concept of ‘medical coverage’.
  2. Simplify and unify the social inquiry by clearly specifying conditions (including the notion of ‘indigence’) for EMC access.
  3. Expand the medical card concept to cover the household—all family members—for a duration of one year.
  4. Specify the care and services covered by EMC.
  5. Extend the Global Medical File (GMF) offer to undocumented migrants.
  6. Simplify EMC funding by streamlining third-party payment.
  7. Improve communication between all participants, especially when disseminating a single summary document in several languages throughout the country.
  8. Improve data collection in order to reliably and objectively monitor costs.

Candice Leblanc

(1) Belgian Health Care Knowledge Centre (KCE) Report on Illegal Resident Health Care Access (in French).

(2) Dr Ines Keygnaert, Prof. Ilse Derluyn and Birgit Kerstens of Ghent University co-signed the KCE report.

A Glance at Marie Dauvrin's bio

2005 Vocational Degree in Nursing, ISEI
2006 Specialisation in Community Health
2008 Bachelor of Science Degree in Public Health, UCL
Since 2011 Volunteer Nurse, Red Cross of Belgium
2013 Doctorate in Public Health Sciences, UCL
Since 2014 Postdoctoral Researcher and Visiting Associate Professor, UCL
Since 2015 Assistant Professor, Parnasse-ISEI

A Glance at Julie Gysen's bio

2011 Baccalauréat in Logopaedics, Haute École de la Province de Liège
2014 Master’s Degree in Public Health, UCL
2014-15 Project Manager, Mutualité chrétienne
Since 2015 Research and Teaching Assistant in Public Health Sciences, UCL

A Glance at Vincent Lorant's bio

1987 Bachelor’s Degree in Sociology, UCL
1988 Bachelor’s Degree in Public and International Affairs, Master’s Degree in Economics, UCL
1990-95 Consultant, UNICEF and Plan International Ecuador
1995-2004 Researcher, School of Public Health, UCL
2002 Doctorate in Public Health, UCL
Since 2004 Professor, UCL

Published on May 13, 2016