LE DROIT LA SANT EST-IL UN PRIVIL GE POUR LES NATIONAUX Workshop, 25 juin 2008, Madrid, Espagne Organisation Inte

1. LE DROIT À LA SANTÉ EST-IL UN PRIVILÈGE POUR LES NATIONAUX?Workshop, 25 juin 2008, Madrid, EspagneOrganisation Internationale pour les Migrations (OIM)  

2. 2 Objectifs de la présentation Personnes concernées par la migration (définition) Relation entre la santé et les droits de l’homme Obstacles à l’application du droit à la santé et recommandations

3. 3 1. Personnes concernées par la migration La migration vers l’Europe et en Europe concerne actuellement plusieurs catégories de personnes, dont: les migrants (en situation régulière ou irrégulière, ou pour des séjours de longue ou courte durée) les étudiants les victimes de la traite des personnes les demandeurs d’asile les refugiés les personnes déplacées Les personnes concernées par le mouvement de retour Their respective migration processes vary widely, and for some, the migration experience poses a number of challenges to physical, mental and social health. “The term migrant is usually understood to cover all cases where the decision to migrate is taken freely by the individual concerned for reasons of “personal convenience” and without intervention of an external compelling factor. This term therefore applies to persons, and family members, moving to another country or region to better their material or social conditions and improve the prospect for themselves or their family ». This definition includes migrants in an irregular situation, seasonal workers, seafarers, project-tied workers, self-emlpyed workers. It excludes sudents, trainee, statless perosns and refugees. Their respective migration processes vary widely, and for some, the migration experience poses a number of challenges to physical, mental and social health. “The term migrant is usually understood to cover all cases where the decision to migrate is taken freely by the individual concerned for reasons of “personal convenience” and without intervention of an external compelling factor. This term therefore applies to persons, and family members, moving to another country or region to better their material or social conditions and improve the prospect for themselves or their family ». This definition includes migrants in an irregular situation, seasonal workers, seafarers, project-tied workers, self-emlpyed workers. It excludes sudents, trainee, statless perosns and refugees.

4. 4 2. Relation entre la santé et les droits de l’homme Quelle est la relation entre la santé et les droits de l’homme? Que signifie le droit à la santé?

5. 5 Quelle est la relation entre la santé et les droits de l’homme? Le droit à la santé est un droit fondamental. Sources: 1. Au niveau international A. Textes généraux B. Textes spécifiques 2. Au niveau régional A. Droit de l’Union Européenne B. Textes du Conseil de l’Europe International Level A. General International Instruments The right to health is recognized as a fundamental human right in numerous international instruments, which extend protection to non-citizens as well as citizens. WHO Constitution (1946) Universal Declaration on Human Rights (1948) Article 25 Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control. International Covenant on Economic, Social and Cultural Rights (1966) Article 12 “The States Parties to the present Covenant recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health (…)”. International Convention on the Elimination of all Forms of Racial Discrimination (1965) Declaration of Alma-Ata (1978) B. Specific International InstrumentsThe instruments listed in this second section aim at protecting the right to health of specific groups, such as migrants/aliens. International Convention on the Protection of the Rights of All Migrant Workers and Members of Their Families (1990) and ILO Conventions, in particular 1949 Convention No. 97 concerning Migration for Employment (Revised 1949) and 1975 Convention No. 143 concerning Migrations in Abusive Conditions and the Promotion of Equality of Opportunity and Treatment of Migrant Workers Declaration on the Human Rights of Individuals who are not nationals of the country in which they are living (1985) Convention relating to the Status of Refugees (1951) Guiding Principles on Internal Displacement (1998) Trafficking and Smuggling Protocols, Supplementing the UN Convention Against Organized Crime (2000) There are also specific instruments dealing with women, children, elderly persons, persons with disabilities, detainees. 2. Regional Level A. European Community Law The competence of the EU in the field of health is based on Article 152 of the EC Treaty Secondary legislation instruments deal with European citizens and third country nationals requiring health care inside the EU as well as with the entitlement to health care for various migrating persons B. CoE Conventions The Convention for the Protection of Human Rights and Fundamental Freedoms (1950) Article 3 the European Court of Human Rights’ case law, states that a state’s failure to provide effective access to health care for irregular migrants may also constitute a violation of Articles 2 (Right to life) and/or 8 (Right to respect for private and family life) ” The European Convention on Social and Medical Assistance (1953) Art 1 European Social Charter of 1961 (revised in 1996) Arts 11 and 13 The European Convention on Social and Medical Assistance and the European Social Charter require that nationals of one State Party lawfully present on the territory of another be afforded medical assistance on terms equal to those of nationals of the second State Party The European Committee of Social Rights, which monitors the application of the European Social Charter, found that, despite the focus on lawful presence, "legislation or practice that denies entitlement to medical assistance to foreign nationals, within the territory of a State Party, even if they are there illegally, is contrary to the Charter” Convention on Human Rights and Biomedicine (1997) It aims at ensuring equitable access to health care of appropriate quality in accordance with the person's medical needs Recommendations of the of the Committee of Ministers to member states Recommendation Rec(2001)12 of the Committee of Ministers to member states on the adaptation of health care services to the demand for health care and health care services of people in marginal situations Recommendation Rec(2006)18 of the Committee of Ministers to member states on health services in a multicultural society Recommendation Rec(2006)10 of the Committee of Ministers to member states on better access to health care for Roma and Travellers in Europe Recommendations of the Parliamentary Assembly Recommendation 1503 (2001) of the Parliamentary Assembly on health conditions of migrants and refugees in Europe Recommendation 1626(2003) of the Parliamentary Assembly on the reform of health care systems in Europe: reconciling equity, quality and efficiency International Level A. General International Instruments The right to health is recognized as a fundamental human right in numerous international instruments, which extend protection to non-citizens as well as citizens. WHO Constitution (1946) Universal Declaration on Human Rights (1948) Article 25 Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control. International Covenant on Economic, Social and Cultural Rights (1966) Article 12 “The States Parties to the present Covenant recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health (…)”. International Convention on the Elimination of all Forms of Racial Discrimination (1965) Declaration of Alma-Ata (1978) B. Specific International InstrumentsThe instruments listed in this second section aim at protecting the right to health of specific groups, such as migrants/aliens. International Convention on the Protection of the Rights of All Migrant Workers and Members of Their Families (1990) and ILO Conventions, in particular 1949 Convention No. 97 concerning Migration for Employment (Revised 1949) and 1975 Convention No. 143 concerning Migrations in Abusive Conditions and the Promotion of Equality of Opportunity and Treatment of Migrant Workers Declaration on the Human Rights of Individuals who are not nationals of the country in which they are living (1985) Convention relating to the Status of Refugees (1951) Guiding Principles on Internal Displacement (1998) Trafficking and Smuggling Protocols, Supplementing the UN Convention Against Organized Crime (2000) There are also specific instruments dealing with women, children, elderly persons, persons with disabilities, detainees.

6. 6 Textes internationaux A. Textes généraux La Constitution de l’OMS (1946) Déclaration universelle des droits de l’homme (1948) Article 25 Convention internationale sur l’élimination de toutes les formes de discrimination raciale (1965) Pacte international relatif aux droits économiques, sociaux et culturels (1966) Article 12 “Les Etats parties au présent Pacte reconnaissent le droit qu'a toute personne de jouir du meilleur état de santé physique et mentale qu'elle soit capable d'atteindre (…)”. Declaration d’Alma-Ata (1978) Constitutions of International Organizations are multilateral agreements according to public international law; therefore the WHO Constitution is binding upon States that are party to that Constitution. Consequently, these States have to comply with the right to health as set out in the Preamble to the WHO Constitution. This wide definition of the Preamble to the WHO Constitution shows the path to follow. In fact, it also takes into consideration mental and physical health, addresses preventive and curative health efforts, and refers to the responsibility of Governments for the health of those in their territory, to non-discrimination, to child health, and to information and participation of the public. The Preamble of the WHO Constitution states the following: (…) Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, political belief, economic or social condition. The health of all peoples is fundamental to the attainment of peace and security and is dependent upon the fullest co-operation of individuals and States. The achievement of any State in the promotion and protection of health is of value to all. Unequal development in different countries in the promotion of health and control of disease, especially communicable disease, is a common danger. Healthy development of the child is of basic importance; the ability to live harmoniously in a changing total environment is essential to such development. The extension to all peoples of the benefits of medical, psychological and related knowledge is essential to the fullest attainment of health. Informed opinion and active co-operation on the part of the public are of the utmost importance in the improvement of the health of the people. Governments have a responsibility for the health of their peoples which can be fulfilled only by the provision of adequate health and social measures. (…) Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19 -22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948. A new draft of the preamble’s first sentence includes the dynamic nature of the state of well-being including also the spiritual aspect. The Declaration of Alma Ata was adopted at the International Conference on Primary Health Care, Alma-Ata, USSR, 6 -12 September 1978 by WHO and UNICEF Member States. The Declaration identified primary health care as the key to the attainment of the goal of Health for All throughout: evolution from local and national conditions; application of interdisciplinary and operational research; priorities of the communities; integration of promotive, preventive, curative and rehabilitative services; community participation and self-reliance; integrated health care system; intersectoral collaboration; and collaboration of responsive health workers. Constitutions of International Organizations are multilateral agreements according to public international law; therefore the WHO Constitution is binding upon States that are party to that Constitution. Consequently, these States have to comply with the right to health as set out in the Preamble to the WHO Constitution. This wide definition of the Preamble to the WHO Constitution shows the path to follow. In fact, it also takes into consideration mental and physical health, addresses preventive and curative health efforts, and refers to the responsibility of Governments for the health of those in their territory, to non-discrimination, to child health, and to information and participation of the public.

7. 7 Textes internationaux B. Textes spécifiques Convention internationale sur la protection des droits de tous les travailleurs migrants et des membres de leur famille (1990) et Conventions de l’OIT numéros 97 et 143 Convention relative au statut des réfugiés (1951) Principes directeurs relatifs au déplacement de personnes à l’intérieur de leur propre pays (1998) Les Protocoles contre la traite de personnes et le trafic illicite de migrants, additionnels à la Convention des Nations Unies contre la criminalité transationale (2000) Textes juridiques spécifiques concernant les femmes, les enfants, les personnes agées, les personnes avec des disablitées, déténus Convention 97 concernant les travailleurs migrants (révisée en 1949) Convention 143 concernant les migrations dans des conditions abusives et sur la promotion de l’égalité de chances et de traitement des travailleurs migrantsConvention 97 concernant les travailleurs migrants (révisée en 1949) Convention 143 concernant les migrations dans des conditions abusives et sur la promotion de l’égalité de chances et de traitement des travailleurs migrants

8. 8 Textes régionauxA. Droit de l’Union Européenne Droit originaire La compétence de l’UE en matière de santé se fonde sur l’article 152 du Traité CE Droit dérivé Le textes concernent les citoyens européens et les ressortissants des pays tiers nécessitant des soins médicaux au sein de l’UE aussi bien que l’accès à la santé de différentes personnes impliquées dans la migration Accords de partenariat euro-méditerrannéens Euro-Mediterranean association agreements, which have been concluded between the European Community and its partners in the Mediterranean, cover the three main areas included in the Barcelona Declaration[1]: political dialogue; establishment of a free trade area; and economic, financial, social and cultural cooperation. They replace the cooperation agreements concluded in the 1970s. All association agreements also include clauses dealing with social and cultural cooperation, as well as a clause defining respect for democratic principles and fundamental human rights, as "an essential element" of the agreement. [1] See:http://www.ladocumentationfrancaise.fr/dossiers/europe-mediterranee/chronologie.shtml. [1]The Barcelona Declaration was adopted at the Euro-Mediterranean Conference of 27 and 28 November 1995. In this Declaration the then 27 Euro-Mediterranean Partners agreed on the establishment of a Euro-Mediterranean Free Trade Area by 2010 through Association Agreements, negotiated and concluded with the European Union, together with free trade agreements between themselves.Euro-Mediterranean association agreements, which have been concluded between the European Community and its partners in the Mediterranean, cover the three main areas included in the Barcelona Declaration[1]: political dialogue; establishment of a free trade area; and economic, financial, social and cultural cooperation. They replace the cooperation agreements concluded in the 1970s. All association agreements also include clauses dealing with social and cultural cooperation, as well as a clause defining respect for democratic principles and fundamental human rights, as "an essential element" of the agreement.

9. 9 Textes régionauxB. Textes du Conseil d’Europe Traités Convention de sauvegarde des droits de l‘homme et des libertés fondamentales (1950) Article 3 Convention européenne d'assistance sociale et médicale (1953) Article Premier Charte sociale européenne (révisée en 1996) Articles 11 et 13 Convention sur les Droits de l'Homme et la biomédecine (1997) -Convention de sauvegarde des droits de l‘homme et des libertés fondamentales Article 3 – Interdiction de la torture Nul ne peut être soumis à la torture ni à des peines ou traitements inhumains ou dégradants. -Convention européenne d'assistance sociale et médicale Article 1 Chacune des Parties contractantes s'engage à faire bénéficier les ressortissants des autres Parties contractantes, en séjour régulier sur toute partie de son territoire auquel s'applique la présente Convention et qui sont privés de ressources suffisantes, à l'égal de ses propres ressortissants et aux mêmes conditions, de l'assistance sociale et médicale prévue par la législation en vigueur dans la partie du territoire considéré. - Charte sociale européenne signée à Paris le 11 décembre 1953. Article 11 – Droit à la protection de la santé En vue d'assurer l'exercice effectif du droit à la protection de la santé, les Parties s'engagent à prendre, soit directement, soit en coopération avec les organisations publiques et privées, des mesures appropriées tendant notamment: à éliminer, dans la mesure du possible, les causes d'une santé déficiente; à prévoir des services de consultation et d'éducation pour ce qui concerne l'amélioration de la santé et le développement du sens de la responsabilité individuelle en matière de santé; à prévenir, dans la mesure du possible, les maladies épidémiques, endémiques et autres, ainsi que les accidents. Article 13 – Droit à l'assistance sociale et médicale En vue d'assurer l'exercice effectif du droit à l'assistance sociale et médicale, les Parties s'engagent: à veiller à ce que toute personne qui ne dispose pas de ressources suffisantes et qui n'est pas en mesure de se procurer celles-ci par ses propres moyens ou de les recevoir d'une autre source, notamment par des prestations résultant d'un régime de sécurité sociale, puisse obtenir une assistance appropriée et, en cas de maladie, les soins nécessités par son état; à veiller à ce que les personnes bénéficiant d'une telle assistance ne souffrent pas, pour cette raison, d'une diminution de leurs droits politiques ou sociaux; à prévoir que chacun puisse obtenir, par des services compétents de caractère public ou privé, tous conseils et toute aide personnelle nécessaires pour prévenir, abolir ou alléger l'état de besoin d'ordre personnel et d'ordre familial; à appliquer les dispositions visées aux paragraphes 1, 2 et 3 du présent article, sur un pied d'égalité avec leurs nationaux, aux ressortissants des autres Parties se trouvant légalement sur leur territoire, conformément aux obligations qu'elles assument en vertu de la Convention européenne d'assistance sociale et médicale, Convention pour la protection des Droits de l'Homme et de la dignité de l'être humain à l'égard des applications de la biologie et de la médecine: Convention sur les Droits de l'Homme et la biomédecine   -Convention de sauvegarde des droits de l‘homme et des libertés fondamentales Article 3 – Interdiction de la torture Nul ne peut être soumis à la torture ni à des peines ou traitements inhumains ou dégradants. -Convention européenne d'assistance sociale et médicale Article 1 Chacune des Parties contractantes s'engage à faire bénéficier les ressortissants des autres Parties contractantes, en séjour régulier sur toute partie de son territoire auquel s'applique la présente Convention et qui sont privés de ressources suffisantes, à l'égal de ses propres ressortissants et aux mêmes conditions, de l'assistance sociale et médicale prévue par la législation en vigueur dans la partie du territoire considéré. - Charte sociale européenne signée à Paris le 11 décembre 1953. Article 11 – Droit à la protection de la santé En vue d'assurer l'exercice effectif du droit à la protection de la santé, les Parties s'engagent à prendre, soit directement, soit en coopération avec les organisations publiques et privées, des mesures appropriées tendant notamment: à éliminer, dans la mesure du possible, les causes d'une santé déficiente; à prévoir des services de consultation et d'éducation pour ce qui concerne l'amélioration de la santé et le développement du sens de la responsabilité individuelle en matière de santé; à prévenir, dans la mesure du possible, les maladies épidémiques, endémiques et autres, ainsi que les accidents. Article 13 – Droit à l'assistance sociale et médicale En vue d'assurer l'exercice effectif du droit à l'assistance sociale et médicale, les Parties s'engagent: à veiller à ce que toute personne qui ne dispose pas de ressources suffisantes et qui n'est pas en mesure de se procurer celles-ci par ses propres moyens ou de les recevoir d'une autre source, notamment par des prestations résultant d'un régime de sécurité sociale, puisse obtenir une assistance appropriée et, en cas de maladie, les soins nécessités par son état; à veiller à ce que les personnes bénéficiant d'une telle assistance ne souffrent pas, pour cette raison, d'une diminution de leurs droits politiques ou sociaux; à prévoir que chacun puisse obtenir, par des services compétents de caractère public ou privé, tous conseils et toute aide personnelle nécessaires pour prévenir, abolir ou alléger l'état de besoin d'ordre personnel et d'ordre familial; à appliquer les dispositions visées aux paragraphes 1, 2 et 3 du présent article, sur un pied d'égalité avec leurs nationaux, aux ressortissants des autres Parties se trouvant légalement sur leur territoire, conformément aux obligations qu'elles assument en vertu de la Convention européenne d'assistance sociale et médicale, Convention pour la protection des Droits de l'Homme et de la dignité de l'être humain à l'égard des applications de la biologie et de la médecine: Convention sur les Droits de l'Homme et la biomédecine  

10. 10 Textes régionauxB. Textes du Conseil d’Europe Recommandations Recommandation (2001)12 du Comité des Ministres aux Etats membres sur l'adaptation des services de soins de santé à la demande de soins et de services des personnes en situation marginal Recommandation (2006)18 du Comité des Ministres aux Etats membres sur les services de santé dans une société multiculturelle Recommandation 1503 (2001) de l’Assemblée Parlementaire sur les conditions sanitaires des migrants et des réfugiés en Europe Recommandation 1626 (2003) de l’Assemblée Parlementaire sur la réforme des systèmes de santé en Europe: concilier équité, qualité et efficacité

11. 11 Que signifie le droit à la santé? Le droit à la santé est le droit de disposer: Des facteurs fondamentaux déterminants de la santé - l'accès à l'eau salubre et potable et à des moyens adéquats d'assainissement, - l'accès à une quantité suffisante d'aliments sains, la nutrition et le logement, - l'hygiène du travail et du milieu et - l'accès à l'éducation et à l'information relatives à la santé, notamment la santé sexuelle et génésique Soins de santé DAAQ Disponibilité, Accessibilité (non discrimination, accessibilité physique, économique, de l’information) Acceptabilité Qualité EU and CoE Member Sates have recognized the right of everyone to the attainable standards of physical and mental health* and the right to receive health care in the event of sickness and pregnancy General legal obligations Respect Protect Fulfil Principle of progressive realization Obligation to take steps, individually and through international assistance and cooperation, especially economic and technical, to the maximum of its available resources with a view to achieving progressively the full realization of the rights... "Core" obligations (helps prioritize what to do e.g. the adoption of a national public health strategy in the framework of AAAQ is a core obligation) "Immediate obligations", e.g. nondiscrimination & obligation to move expeditiously and effectively & to deliberate, concrete & targeted steps - Important to distinguish government incapacity vs. unwillingness - Use indicators (structural, process & outcome) and benchmarks Freedom from discrimination “in access to health care and the underlying determinants of health, as well as to means and entitlements for their procurement, on the grounds of race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth, physical or mental disability, health status, (including HIV/AIDS), sexual orientation, civil, political, social or other status, which has the intention or effect of nullifying or impairing the equal enjoyment or exercise of the right to health”. Specific legal obligations “States are under the obligation to respect the right to health by, inter alia, refraining from denying or limiting equal access for all persons, including prisoners or detainees, minorities, asylum seekers and illegal immigrants, to preventive, curative and palliative health services (…)” (CESCR General comment on the right to the highest attainable standard of health, article 12 ICESCR) Disponibilité, Accessibilité (non discrimination, accessibilité physique, économique, de l’information) Acceptabilité Qualité EU and CoE Member Sates have recognized the right of everyone to the attainable standards of physical and mental health* and the right to receive health care in the event of sickness and pregnancy General legal obligations Respect Protect Fulfil Principle of progressive realization Obligation to take steps, individually and through international assistance and cooperation, especially economic and technical, to the maximum of its available resources with a view to achieving progressively the full realization of the rights... "Core" obligations (helps prioritize what to do e.g. the adoption of a national public health strategy in the framework of AAAQ is a core obligation) "Immediate obligations", e.g. nondiscrimination & obligation to move expeditiously and effectively & to deliberate, concrete & targeted steps - Important to distinguish government incapacity vs. unwillingness - Use indicators (structural, process & outcome) and benchmarks Freedom from discrimination “in access to health care and the underlying determinants of health, as well as to means and entitlements for their procurement, on the grounds of race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth, physical or mental disability, health status, (including HIV/AIDS), sexual orientation, civil, political, social or other status, which has the intention or effect of nullifying or impairing the equal enjoyment or exercise of the right to health”. Specific legal obligations “States are under the obligation to respect the right to health by, inter alia, refraining from denying or limiting equal access for all persons, including prisoners or detainees, minorities, asylum seekers and illegal immigrants, to preventive, curative and palliative health services (…)” (CESCR General comment on the right to the highest attainable standard of health, article 12 ICESCR)

12. 12 Principes essentiels du droit à la santé a) De garantir le droit d'avoir accès aux équipements, produits et services sanitaires sans discrimination aucune, notamment pour les groupes vulnérables ou marginalisés; b) D'assurer l'accès à une alimentation essentielle minimale qui soit suffisante et sûre sur le plan nutritionnel, pour libérer chacun de la faim; c) D'assurer l'accès à des moyens élémentaires d'hébergement, de logement et d'assainissement et à un approvisionnement suffisant en eau salubre et potable; d) De fournir les médicaments essentiels, tels qu'ils sont définis périodiquement dans le cadre du Programme d'action de l'OMS pour les médicaments essentiels; e) De veiller à une répartition équitable de tous les équipements, produits et services sanitaires; f) D'adopter et de mettre en œuvre au niveau national une stratégie et un plan d'action en matière de santé publique. Observation générale numéro 14 du Comité sur les droits économiques, sociaux et culturels

13. 13 Le droit à la santé Obligations juridiques générales Respecter Protéger Mettre en œuvre Principe de réalisation progressive Observation Générale numéro 14 du Comité sur les droits économiques, sociaux et culturels States parties have immediate obligations in relation to the right to health, such as the guarantee that the right will be exercised without discrimination of any kind (art. 2.2) and the obligation to take steps (art. 2.1) towards the full realization of article 12. Such steps must be deliberate, concrete and targeted towards the full realization of the right to health. Principle of progressive realization: - Obligation to take steps, individually and through international assistance and cooperation, especially economic and technical, to the maximum of its available resources with a view to achieving progressively the full realization of the rights... - "Core" obligations (helps prioritize what to do e.g. the adoption of a national public health strategy in the framework of AAAQ is a core obligation) "Immediate obligations", e.g. nondiscrimination & obligation to move expeditiously and effectively & to deliberate, concrete & targeted steps - Important to distinguish government incapacity vs. unwillingness - Use indicators (structural, process & outcome) and benchmarks Freedom from discrimination “in access to health care and the underlying determinants of health, as well as to means and entitlements for their procurement, on the grounds of race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth, physical or mental disability, health status, (including HIV/AIDS), sexual orientation, civil, political, social or other status, which has the intention or effect of nullifying or impairing the equal enjoyment or exercise of the right to health”. (General comment on the right to the highest attainable standard of health, article 12 ICESCR) States parties have immediate obligations in relation to the right to health, such as the guarantee that the right will be exercised without discrimination of any kind (art. 2.2) and the obligation to take steps (art. 2.1) towards the full realization of article 12. Such steps must be deliberate, concrete and targeted towards the full realization of the right to health. Principle of progressive realization: - Obligation to take steps, individually and through international assistance and cooperation, especially economic and technical, to the maximum of its available resources with a view to achieving progressively the full realization of the rights... - "Core" obligations (helps prioritize what to do e.g. the adoption of a national public health strategy in the framework of AAAQ is a core obligation) "Immediate obligations", e.g. nondiscrimination & obligation to move expeditiously and effectively & to deliberate, concrete & targeted steps - Important to distinguish government incapacity vs. unwillingness - Use indicators (structural, process & outcome) and benchmarks Freedom from discrimination “in access to health care and the underlying determinants of health, as well as to means and entitlements for their procurement, on the grounds of race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth, physical or mental disability, health status, (including HIV/AIDS), sexual orientation, civil, political, social or other status, which has the intention or effect of nullifying or impairing the equal enjoyment or exercise of the right to health”. (General comment on the right to the highest attainable standard of health, article 12 ICESCR)

14. 14 Le droit à la santé Obligations juridiques spécifiques “Les États sont en particulier liés par l'obligation de respecter le droit à la santé, notamment en s'abstenant de refuser ou d’amoindrir l'égalité d'accès de toutes les personnes, dont les détenus, les membres de minorités, les demandeurs d'asile et les immigrants en situation irrégulière, aux aux soins de santé prophylactiques, thérapeutiques et palliatifs, en s'abstenant d'ériger en politique d'État l’application de mesures discriminatoires et en évitant d'imposer des pratiques discriminatoires concernant la situation et les besoins des femmes en matière de santé (…)” Observation Générale numéro 14 du Comité sur les droits économiques, sociaux et culturels

15. 15 Droits liés à la santé Le droit à la vie Le droit à la l’égalité et à la non-discrimination Le droit a l’intégrité physique Le droit à l’identité Le droit à la vie privée Le droit d’accès à l’information Le droit à la nourriture Le droit au logement Le droit à la sécurité sociale Le droit de ne pas être soumis à la torture et à des traitements inhumains et dégradants Le droit de bénéficier du progrès scientifique Le droit à l’éducation Les droits à la liberté d’association, de réunion e de mouvement

16. 16 Obstacles à l’accomplissement du droit à la santé et recommandations Le droit à la santé s’applique à tout être humain indépendamment de son statut légal. En Europe subsistent toutefois des obstacles à l’application du droit à la santé pour les personnes concernées par la migration.

17. 17 Migrants irréguliers Une femme d’origine africaine a été soignée pour fièvre, infection et faiblesses au service d’urgence de l’hôpital universitaire de la ville où elle était domiciliée. Quand elle a présenté une assurance médicale inconnue, l’administration de l’hôpital a eu des suspicions et a appellé la police pour vérifier son statut d’immigration. La police l’a ramenée au commissariat et peu de temps après elle a été ramenée aux urgences. Une opération a été planifiée pour le lendemain. Toutefois, la femme a quitté l’hôpital avant l’opération car elle craignait de se faire expulser tout de suite après. * *Braun & Würflinger 2001 Irregular migrants are those persons who have not been granted permission to enter or to stay in a given country An Irregular migrant refers to an individual who, owing to irregular entry or the expiry of his/her visa, lacks legal status in a transit or host country. The term applies to migrants who infringe a country’s admission rules and any other person not authorized to remain in the host country (Glossary on Migration, International Migration Law Series, IOM, 2004). Irregular migrants are also referred to as clandestine, illegal, undocumented migrants or migrants in an irregular situation. The term “irregular” is preferable to “illegal” as the latter carries a criminal connotation and is seen as denying migrants’ humanity The irregular migrant is not granted a complete right to health care in various WHO European Region MS. For example, the Danish law on health care limits irregular migrants’ access to the national health care system to urgent treatment. In Germany, in principle, irregular migrants are granted the same right to health care as asylum seekers, being entitled to emergency care, care in pain situations, or indispensable care in order to preserve health (for example avoiding long-term aggravation or complications of diseases). The implementation of these provisions conflicts, however, with the Aufenthaltsgesetz, under which public servants have to report the details of any irregular migrant they encounter during their job, and anyone who helps an individual without a regular residence permit can be punished if assistance is provided for financial gain, or if it is done repeatedly or for the benefit of several foreigners. In countries like Spain, Italy, Portugal, Belgium, the Netherlands and the UK, there are various obstacles to the implementation of national legislation guaranteeing irregular migrants’ right to health care.  Irregular migrants are those persons who have not been granted permission to enter or to stay in a given country An Irregular migrant refers to an individual who, owing to irregular entry or the expiry of his/her visa, lacks legal status in a transit or host country. The term applies to migrants who infringe a country’s admission rules and any other person not authorized to remain in the host country (Glossary on Migration, International Migration Law Series, IOM, 2004). Irregular migrants are also referred to as clandestine, illegal, undocumented migrants or migrants in an irregular situation. The term “irregular” is preferable to “illegal” as the latter carries a criminal connotation and is seen as denying migrants’ humanity The irregular migrant is not granted a complete right to health care in various WHO European Region MS. For example, the Danish law on health care limits irregular migrants’ access to the national health care system to urgent treatment. In Germany, in principle, irregular migrants are granted the same right to health care as asylum seekers, being entitled to emergency care, care in pain situations, or indispensable care in order to preserve health (for example avoiding long-term aggravation or complications of diseases). The implementation of these provisions conflicts, however, with the Aufenthaltsgesetz, under which public servants have to report the details of any irregular migrant they encounter during their job, and anyone who helps an individual without a regular residence permit can be punished if assistance is provided for financial gain, or if it is done repeatedly or for the benefit of several foreigners. In countries like Spain, Italy, Portugal, Belgium, the Netherlands and the UK, there are various obstacles to the implementation of national legislation guaranteeing irregular migrants’ right to health care.

18. 18 Victimes de la traite des personnes The Council of Europe Convention on Action Against Trafficking in Human Beings, require States, if they ratified it, to: a) provide a periode de reflexion of 30 days to victims of trafficking, and thereafter b) issue a permis de sejour renouvelable to victims of trafficking if “the competent authority considers that their stay is necessary owing to their personal situation” or “the competent authority considers that their stay is necessary for the purpose of their co-operation with the competent authorities in investigation or criminal proceedings.” BUT a) Wide differentiation exists among countries concerning the length of the reflection period granted. Longer reflection periods provide a victim with the opportunity to recuperate and to make an informed decision. b) Countries mostly require the victims to cooperate with law enforcement and criminal investigations in order to grant them residence permit , although this contrast with human rights principles. Victim protection SHOULD NOT be linked to a victim’s agreement to testify. The Council of Europe Convention on Action Against Trafficking in Human Beings, require States, if they ratified it, to: a) provide a periode de reflexion of 30 days to victims of trafficking, and thereafter b) issue a permis de sejour renouvelable to victims of trafficking if “the competent authority considers that their stay is necessary owing to their personal situation” or “the competent authority considers that their stay is necessary for the purpose of their co-operation with the competent authorities in investigation or criminal proceedings.” BUT a) Wide differentiation exists among countries concerning the length of the reflection period granted. Longer reflection periods provide a victim with the opportunity to recuperate and to make an informed decision. b) Countries mostly require the victims to cooperate with law enforcement and criminal investigations in order to grant them residence permit , although this contrast with human rights principles. Victim protection SHOULD NOT be linked to a victim’s agreement to testify.

19. 19 Recommandations Assurer la reconnaissance officielle du droit à la santé pour tous dans les pays membres de l’UE Éliminer les obstacles à l’accomplissement du droit à la santé pour tous.

20. Paola Pace Organisation Internationale pour les migrations (OIM) ppace@iom.int +41 22 717 92 76