Asylum-seekers’ and refugees’ access to healthcare in Germany and the UK
Sioned Ellis, MSc Public Policy, University of Edinburgh
Asylum-seekers and refugees (ASRs) are particularly vulnerable to a number of health risks, from infectious diseases acquired in transit to psychological trauma resulting from war or persecution. This makes the accessibility of healthcare services paramount for them, but in many countries, they face significant barriers to accessing such services.
Analysis of these barriers herein aims to demonstrate the need for ASRs to be granted full access to health services from the point of their arrival in a host country. While said barriers are common across Europe, their presentation can vary by country. Comparisons between the UK and Germany can thus be particularly valuable given the typical distinctness of the countries’ approaches to asylum policy.
Before making such comparisons, however, it is important to identify the wider consequences of ASRs’ exclusion from healthcare wherever they seek refuge. These include deterioration in their health outcomes, knock-on effects on their quality of life, and increased pressure on the emergency services to which they are forced to turn as a last resort.
The EU’s standards for the treatment of ASRs are contained in the Common European Asylum System (CEAS). The CEAS stipulates that ASRs should have access to necessary and emergency healthcare; however, its lack of detail about cost raises questions of affordability. Even in countries with fully state-funded health services, ASRs may be required to pay for their care depending on their documentation and legal status. Emergency services are often excluded from costs but this inevitably pushes people to either overuse such services in non-emergency situations or, more commonly, to delay treatment until their health reaches a breaking point.
ASRs are further deterred from accessing healthcare by the practice of data sharing between health and immigration authorities; in the UK in 2016, for example, data sharing by the NHS caused the Home Office to be alerted to the presence of 5,854 undocumented migrants. The practice has since been curtailed in the UK but still occurs in cases of overdue payments for treatment. Perhaps as a consequence of this, ASRs are more likely to rely on NGOs for certain health concerns, specifically for support following rape and other violence in the UK and for mental healthcare in Germany.
Another issue is that frequent internal relocations by immigration authorities disrupt ASRs’ medical treatment and impede the development of long-term trusting relationships with care providers. Furthermore, availability of translation services is not guaranteed and patients often rely on informal translation by family members or unqualified support workers which can result in miscommunication.
This is particularly problematic in discussions of sensitive subjects like mental health. Rates of mental health problems are disproportionately high among ASRs, but fears of stigmatisation often prevent them from seeking help. Manifestations of mental distress can vary considerably between different cultures; in non-western cultures they are often expressed as physical symptoms such as non-specific pain, so western clinicians must be attentive to this. In addition, many ASRs do not know what services are available to them, others lack trust in western medicine, while some are not aware that conditions like anxiety can be treated.
The UK vs Germany
Uncharacteristically, in the case of healthcare, the UK’s provisions for ASRs are more generous than Germany’s. Nonetheless, the UK system is certainly not without flaws.
UK-wide, ASRs generally have free access to primary, secondary and emergency health care and are exempt from the Immigration Health Surcharge faced by regular migrants. In Scotland and Wales, this does not change if one’s application for asylum is rejected, but in England, continued free access depends on the type of legal protection, if any, that one is subject to as a rejected asylum-seeker. Undocumented migrants, on the other hand, face charges after receiving urgent NHS care and before receiving non-urgent care, at 1.5 times standard costs.
Furthermore, while guidance exists for clinicians on ASRs’ health needs and rights, they report feeling out of their depth when treating these patients, which is exacerbated by low service capacity. GP practices are not legally permitted to reject applications for registration from patients based on race, ethnicity, nationality, citizenship and so on, but some are reluctant to accept ASRs as they are more likely to require translators, for example, which represent additional costs.
By contrast, in Germany, asylum-seekers’ and refugees’ exclusion from healthcare services is explicit and intentional. The Asylum-seekers Benefit Act states that after 15 months of residence in Germany, ASRs gain the same rights to healthcare as the general population, but for the first 15, they have only a basic entitlement to emergency and acute healthcare, and require a health voucher to access non-emergency care.
The Asylum Procedure Acceleration Act of 2015 introduced an electronic health card which reduces restrictions to access, but only in five of sixteen states. Differentiation between categories of asylum-seeker also adds complexity as unaccompanied minors are entitled to total healthcare coverage but those seeking asylum with their families are subject to the Asylum-seekers Benefit Act restrictions. This is reflective of the layers of bureaucracy that are common across the health systems of both countries.
Barriers to accessing public healthcare services in general are often upheld by governments due to fears of ‘health tourism’ (where migrants enter a country to take advantage of its health services) or are a result of linguistic and cultural obstacles, poor signposting to services, or financial or logistical difficulties. Policy officials often attempt to justify the exclusion of certain groups from public services by financial constraints. But as with the right to work, granting ASRs full access to healthcare is beneficial not only to them but also to the countries that host them.
This is because it reduces the costs incurred from emergency care by prioritising more preventative treatment. Thus, unless asylum-seekers and refugees are to be excluded from all forms of healthcare, including emergency care – which would be morally disastrous – then it is only logical to ensure they have the same rights to healthcare as natives.
While Germany is comparatively liberal in other areas of asylum policy (for example, the right to work), it needs an expansion of access to health services before its rules can be considered to be mutually beneficial to ASRs and the German state. On the other hand, in the UK, the NHS is immediately available (notwithstanding its infamous waiting times) but not always inclusive of ASRs.
Both countries should therefore take the World Health Organisation’s advice to fully include this group in public health systems. The best time to do this would have been decades ago. But with increasing numbers of asylum-seekers arriving in Germany from Ukraine, and already-settled refugees from elsewhere still facing hugely unequal health outcomes in both countries, the next best time is now.