Elena Tulupová 1,3 , Helena Hnilicová 1 , Karolína Dobiášová 1,2

2. Health aspects of integration of third-countries nationals in the Czech Republic in view of qualitative research Elena Tulupová1,3, Helena Hnilicová1, Karolína Dobiášová 1,2 Charles University Prague, First Faculty of Medicine Institute of Public Health and Medical Law 2. Faculty of Social Science, Institut of Sociology 3. Consortium of the NGO´s dedicated to migration

3. Content • Background data on migrants in the Czech Republic • Czech integration policy • Legal framework of migration in the Czech Republic • The Czech health system and migrants’ entitlement to health care • Public health insurance x Commercial health insurance • Details about migrants referred to commercial health insurance • Commercial health insurance and related barriers in access to health care • Migration related health risks and healthcare utilization • What is needed - public and political initiatives • Conclusion and Summary

4. 1. Background data on migrants in the Czech Republic Since the 1990s, the Czech Republic has been among the countries with the fastest growing immigration. In 1990 – 2006, the number of foreigners increased almost tenfold. The immigrants’ inflow is caused by the work migration. Total number of migrants (2011): 424 000 (4,2 % of population) EU – Third countries 32 % x 68% Permanent residents 40% - women 40 % Long-term residents 60% - men 60 % Economic activity 87 % Age structure Employees 70 % 20 – 65 77 % Self employed 30 % Children and adolescents 20 % Older 65 years 3 % Nationality structure Ukraine 30 % Slovakia 17 % Vietnam 14 % Russia 7 % Source: Czech Statistical Office 2011

5. Migrants in the CR by citizenship Migrants by citizenship (31.12. 2010) Source: Czech Statistical Office, Foreigners in the Czech Republic 2011

6. Czech integration policy • The main goal: Migrants full incorporation into the majority society should be achieved - in the long-term perspective. • The main characteristics: Harmonize the domestic migration policy with EU priorities, and at the same time to make the migration´s character correspond to the domestic economy needs. • The key prerequisites of a successful integration in the Czech Republic: • language competencies • economic self-sustainability • orientation in the society: health/healthcare aspects of orientation belongs to very important - to understand how healthcare sytem works; entitlement and access to healthcare.

7. Health aspects of integration • The Czech health system • Migrants’ entitlement to health care • Unequal access of third countries migrants to Czech public health insurancein comparison to EU migrants • Details about migrants referred to commercial health insurance

8. CzechHealth Care System • Needed healthcare is considered as basic human right and guaranted by the Czech Constitution • Universal access and universal coverage of the entire • population • Public health insurance (Bismarckian model):health care is provided to the allCzech residentsand to other entitled persons on the basis of mandatory public healthinsurance • Insurance premium (13,5 % of gross wage) ispaid together by employer (9%) and employee (4,5%) • Children, students up to 26 years, seniors, handicapped, mothers on maternity leaves, prisoners, unemployed, poor people do not pay health insurance.

9. CzechHealth Care System • Who is „other entitled persons“ to public health insurance: • - All citizens of EU member states (incl. children • and other dependents) living in the CR on the long-term • basis • - Asylum seekers • Migrants from third counties are entitled to public health insurance only when: • - they have permanent residence status (40% of migrants) • - they are employees of the employers (companies) • registered in the CR ( i.e. work status „empoyee“) • Note: Permanent residence status can be given after 5 years of ongoing (not interrupted) long- term stay

10. Legal Framework: Czech Alien Act • Health insurance is set up as an necessary condition for visa and work permit applications. • All migrants are obliged to document that they have valid health insurance for a whole period of stay in the CR.

11. Third countries migrants’ entitlement to health care • Third countries migrants entitled to public health insurance (employees and permanent residents) can follow this requirement without any problems; As all other Czechs - migrants have the full right and duty to participate at public health insurance • Third countries migrants/employees participate at public health insurance immediately as they are emloyed by the employer (company, organisations, etc.) registered in the Czech Republic • They have assured a scope of health care equaly to the Czechs and to EU citizens residing in the CR; • Migrants not entitled to public health insurance - self employed and the dependents of all third countries migrants without permanent residence(children, parents, partners, students) have to purchase commercial health insurance.

12. Details about migrants referred to Commercial health insurance • Overall number of migrants referred to commercial health insurance is estimated 100 000 -120 000 ( about 1/4 of all migrants) • Self-employed, partners, children of the Ukrainians, Russians, other former USSR citizens, Vietnamese, Americans, Canadians, Australians, citizens of the former Yugoslavia, China, Japan, Mongolia, Nigeria… • To be insured for health care in commercial scheme - there are many barriers in real access to health care. • In practice, migrants insured within commercial health insurance are not guaranteed with all needed health care • Ethical consequences of this situation are significant…

13. Details about Czech Commercial health insurance for migrantsI • It is special health insurance dedicated only to migrants • This commercial health insurance is not a pretension; risk clients might be refused:the most vulnerable groups are children, esp. prematurely born children or children born disabled or with congenital defects. They usually stay uninsured. • It is market and for profit oriented, minimally regulated by the law • Scope of care covered does not correspond with the health needs of people residing and working in the Czech territory on the long term basis (mostly for several years). • In comparison to public health insurance - conditions of commercial health insurance are significantly worse for the migrants; • In practice: Although migrants are insured in commercial health program - they have to pay some health care in cash! • Migrants are never sure weather provided health care will be fully paid by commercial health insurance company!

14. Details about Czech Commercial health insurance for migrants II • The scope of care as well as financial coverage are limited.Ceiling for the financial coverage is minimum as 60 000 Euros • No commercial insurance company will insure a migrant with a chronic disease. The insurance contract is tailored to the results of medical examination ( necessary condition for insurance contract ), risk selection. • Some chronic diseases and serious health problems are not covered at an appropriate level (in comparison to public health insurance). • Examples of uncovered care: • Insulin dependent diabetes, infectious hepatitis, sexual transmitted diseases, AIDS, mental disorders, hemodialysis, rehabilitation, alcohol and drug addiction treatment, congenital defects and all events whose cause or symptoms originated before insurance contract – pre-existing conditions. • Commercial health insurance does not correspond with other current Czech health legislation ( Public Health Protection Act; Health Services Act)

15. Details about Czech Commercial health insurance for migrants III • Since 2010 prenatal and obstetric care have to be included in standard commercial health insurance (reaction to long-term criticism of commercial insurance) • Health care for newborn child is not included automatically, there is possibility to purchase supplementary insurance • Supplementary health insurance for newborns is expensive and it is limited in terms of time (maximally till 2 month of child age) and financial coverage (maximum 24 000 Euros) • Health Insurance has to be paid in advance for the whole insurance period - at least for 6 months • For the most of migrants, mainly for families with children, commercial health insurance represents significant financial burden and thus creates one of the barriers the family reunification

16. Legislation and practice • The Czech physicians are obliged to provide all necessary acute care to all patients (e.g.uninsured children, illegal migrants ) under the same conditions as for any other patient • They do it - but nobody pays for that health care. • Consequently- some part of health care provided to migrants remains unpaid. • Unpaid hospital care costs constitutes approx. 10 % of the overall costs for healthcare provided to foreigners every year. • Source: Czech Statistical Office, Foreigners in the Czech Republic 2009, 2010).

17. Migrants access to health care in qualitative research 2010 • Objective: • Identify the main barriers in access to health care from perspective of • Health care providers • Migrants • Method: • 36 semi-structured interviews • Sample of respondent: • purposeful sample of 18 health care providers (14 physicians and 4 nurses) • purposeful sample of 18 migrants from third countries (Ukraine, Vietnam, Russia, Moldavia, Mongolia, Belorussia, USA, etc.)

18. Results The folloving categories of obstacles/barriers/risks were identified: • Financial coverage of health care for migrants • Migrants´ informations • Language barriers • Culture differences • Protection against infectious diseases

19. Financial coverage of health care provided to migrants from the perspective of health professional • All respondents considered this area as making obstacles in their practice. There were identified three key issues: • Scope of care in commercial health insurance: not clearly defined, many exclusions, high risk of refusion of reimbursement of provided care • Complicated administration: telephone discussion with insurance officers is sometimes needed etc., a part of care is provided as „charity“esp. in out-patient area • Uncovered care – a certain part of health care stayed uncovered;

20. Financial coverage of health care provided to migrants from the perspective of migrants • Inappropriate /insufficient scope of care guaranteed by the commercial health insurance. • Third country migrants consider current Czech legislations to be unfair and discriminative! • The most criticism addressed the fact, that a significant part of third countries migrants children is not entitled to public health insurance! • Existence of so called „ uninsurable“ children (born with congenital defects, chronic disease, premature born children ) is perceived by all migrants (incl. those without children) to be unethical. • Some respondents experienced the situation, when health professional first of all required valid health insurance permit guarantying that needed health care will be reimbursed and after than they provide needed help. I think, situaation like here is everywhere,.. Nobody is interested in human being, only money and money …Everybody wants to earn a lot of money. They are interested only who will pay for. In Russia, it is another case. First of all they treat patient and then they wait how it will be… If patient is able to pay so he will pay, if not never mind….I miss here (in CR) human feelenigs, everythig here is calculated through money“ (man, Ukrajine, 34 years)

21. Information of migrants • Both, migrants anf health professionals mentioned the following issues: • Migrants do not know how Czech health care system works • Migrants do not know or understand all conditions of commercial health insurance. • „In the last year we treated more often migrants who have commercial health insurance. They were sure that health care for them could be reimbursed. And it was not true. I think that migrants do not understand enough to insurance contract conditions. Insurance officials do not inform migrants about risks and limits of insurance contract...“ (nurse, psychiatric hospital)

22. Language barriers • Health professional • - Physicians and nurses are never sure whether migrants understand properly what they say or not. If there is interpretor, quality od interpretation is also qustionable… • They are affraid of a determination of wrong diagnosis and risk of malpractice. • Interpretation as such is risky from the point of medical secret maintainance; it is common that interpretators are relatives, children. • Migrants • - Migrants complain that physicians ask them to come to ambulance with their own interpretator • - Official interpretator services are too expensive for the most of migrants.Threfore they use family members as interpretors. It is quite common among Vietnamees.There are many practical limits (limited vocabularyof children), emotional and ethical barriers (too sensitive topic) especially in case of children interpreting to their parents.

23. Culture related barriers Doctors and nurses Both groups reported that they don’t consider Ukranians and Russians as a culturally different group, through some differences were noticed - in particular, higher threshold of pain sensitivity and more speedy healing. Vietnamese, especially children, were repeatedly characterized as more patient, less emotive and moresubordinate. Doctors have an opinion that majority of migrants, in general appreciated the Czech health system and professional medical care. Migrants Didn’t reported a cultural difference as a significant barrier in the health care consumption. Cases of complaints: migrants from developed countries (USA, Canada) concerning “paternalistic” approach from the side of doctors, unsatisfactory communication and non-sufficient responsiveness of health care workers.

24. Protection against infectious diseases Doctors and nurses Health care workers strongly recognize the risk for public health connected with exclusion of STDs andHIV/AIDS from coverage with commercial insurance. „And how these sexual diseases are cured?…These people go to check only when it is already horrible. But often there are diseases which are hidden or don’t cause a big discomfort, and this person can spread the infection“(physician N. 1) Migrants With higher level of education are dissatisfied with exclusion of infectious diseases from commercial insurance „I am very unsatisfied with commercial insurancedue to very limited care. For example, it doesn’t cover a treatment of suspicious diseases.“ (TBC, syphilis, etc.) (female, Mongolia, 23 years)

25. Conclusion – what is needed - dodělat • Elimination of discrimination and existing inequalities in access to public health insurance should be targeted in the Czech government migration policy agenda as one of the priorities. • Availability of public health insurtance for all children living at the territory of the CR will improve pre-conditions for family re-unification especially for Ukrainian families (no financial burden connected to health care). • Public health protection: to assure adequate treatment by inclusion of sexually transmitted diseases and HIV /AIDS into commercial health insurance; to provide migrants with information how to protect against infection diseases; • Improvement information: lack of information on the Czech healthcare system (rights and duties, services network, practicalities) was identified as another obstacle which migrants have to face using the health services, esp. migrants not speaking Czech.

26. Thank you for your attention !