Norway has committed to the UN’s Sustainable Development Goals. Securing universal health coverage for all is one of the key objectives. This commitment challenges Norwegian practice and legislation relating to undocumented migrants’ access to healthcare services in Norway.
In 2015, the Millennium Development Goals were replaced by the UN’s Sustainable Development Goals, which introduced new perspectives on global health (1). Whereas the Millennium Development Goals had highlighted poverty; the Sustainable Development Goals are broader in scope and aim to address poverty, inequality and climate change. While the Millennium Goals focused on low and middle-income countries, the Sustainable Development Goals apply for all countries – the goals are universal.
Universal health coverage is one of the main health-related objectives. The aim is to ensure that everyone has access to affordable essential healthcare. Universal health coverage means that high-quality services are accessible to all at a price that does not cause financial hardship. As countries gear towards the goal of universal health coverage, the World Health Organisation (WHO) recommends that decision-makers focus on extending coverage along three different dimensions: to previously non-covered groups (population - who is covered?), to services that were previously not provided (which services are covered?), and by reducing direct payments (proportion of the costs covered) (2).
While the sustainable development goals are global, it is the responsibility of member states to ensure that the goals are reached. In a world where 244 million people do not live in their country of citizenship – 8 % of whom are refugees (3, 4) – challenges arise. Whose task is it to ensure that the goal of universal health coverage is reached for those who have no identity papers? As Norwegian doctors and healthcare professionals meet undocumented migrants in their everyday practice, they are forced to grapple with health coverage issues of global concern.
Who should have access to healthcare services?
The right to the highest sustainable standard of health is recognised in the European Convention on Human Rights, the UN International Covenant on Economic, Social and Cultural Rights, and in other international treaties and conventions. By ratifying these documents, countries such as Norway have committed to protect the human rights of anyone who resides within its borders (5). Furthermore, the Norwegian Constitution and the Human Rights Act stipulate that Norwegian authorities are responsible for ensuring that human rights are protected by the nation’s legal system. Norway has been criticised by the UN, among others, for failing to ensure that undocumented migrants receive healthcare beyond emergency assistance (6).
There are considerable differences between the health services available to members of the Norwegian National Insurance scheme and those available to undocumented migrants. In most countries, the latter group is not covered by the public health service in the same way as permanent residents. There are however considerable differences between countries when it comes to healthcare provision for undocumented migrants. In countries like Spain and Sweden, people without identity papers are entitled to receive certain medical services beyond emergency care, while in Belgium and the Netherlands they have access to the same health services as the rest of the population (7). A middle-income country such as Thailand stands out in that it offers universal health coverage for everyone residing in the country, including refugees and undocumented migrants (8). In this context, Norwegian policies are restrictive; the current strategy is similar to that of Poland and Bulgaria (7). This has created particularly striking differences between the healthcare services available to undocumented migrants and those available to members of the Norwegian welfare state.
Which health services should be covered?
Undocumented migrants in Norway have limited access to health services and, with a few exceptions, their entitlement is restricted to emergency healthcare. According to Norwegian regulations (“Forskrift om tjenester til personer uten fast opphold”), migrants with no legal right to remain are only entitled to receive ‘immediate medical assistance if intervention cannot wait without risk of imminent death, permanent severe disability, serious injury or acute pain’ (9). Some groups, such as children and pregnant women, have access to services beyond this minimum.
A Norwegian study shows that in everyday practice, it can be difficult for healthcare professionals to define what constitutes ‘immediate medical assistance that cannot wait’ (10), particularly if the healthcare workers have neither talked to nor examined the patient. For instance, should patients with progressing diabetes have to wait until they develop ketoacidosis before medical care is offered? How psychotic does a patient have to be before healthcare is provided? Healthcare workers interpret the Norwegian legislation in different ways – some are disinclined to offer healthcare, while others provide services beyond emergency assistance (10, 11).
Undocumented migrants also encounter practical barriers. They often lack information about health services and their own entitlements, and may be living in fear of deportation. This may affect the degree to which undocumented migrants seek medical assistance when they are in need of healthcare. In response to the limited health services available to undocumented migrants, volunteer healthcare centres for undocumented migrants have been established in Oslo and Bergen. These centres report that patients present with illnesses ranging from upper respiratory tract symptoms to chronic pain, diabetes and acute psychosis. The healthcare centre in Bergen, which is open one evening a week, reported a total of 236 consultations in 2016. The majority of patients were young adults from countries in the Middle East, and mental health was the most frequent cause of consultation (12). It is unclear whether undocumented migrants who make use of these services would have received medical assistance from the Norwegian health care system, and whether they meet the formal criteria for accessing its services. These patients may well be using the volunteer-led healthcare centres because they are of limited means, feel ill at ease with using public health services, or are unaware of their own rights.
To what extent should undocumented migrants pay for health services?
Undocumented migrants in Norway are charged for making use of health services, as reimbursements and subsidised medical care are only available to members of the National Insurance scheme. If they cannot pay, patients will find it difficult to access the health services that they are formally entitled to . General practitioners who treat undocumented migrants do not get their costs reimbursed. The same applies in the specialist health service.
Because the health trusts are not reimbursed by the National Insurance scheme for healthcare services provided to undocumented migrants, they demand, to varying degrees, out-of-pocket payment for care provided, such as emergency caesarean sections (13). Undocumented migrants in Norway have been found to put off seeking healthcare due to a lack of funds (14). Studies from low and middle-income countries show that high out-of-pocket charges for health services may cause real financial hardship for patients (15).
Towards universal health coverage in Norway?
Undocumented migrants in Norway do not have access to universal health coverage. The Norwegian public health service provides emergency medical care, but this can be costly. There are relatively few private providers of medical services, and the out-of-pocket payments can be very high. The home countries of undocumented migrants rarely provide health services. Undocumented migrants thus find themselves in a situation where their access to healthcare services is restricted by law, and where financial and other practical barriers further restrict their access to medical care.
Access to healthcare services for undocumented migrants is often linked to immigration policy. Restricting access to the welfare system may be seen to form a part of this strategy; migrants should never be seen to benefit from gaining illegal access to the country (10). Liberal access to healthcare services for undocumented migrants may be considered to encourage ‘health tourism’ in that people in ill health may choose to migrate to Norway for the purpose of accessing expensive treatments such as cancer drugs or treatment against auto-immune diseases. However, very few undocumented migrants quote access to health services as a reason for migrating to an EU country (16). In humanitarian and professional healthcare circles there is broad consensus that medical treatment must be offered based on need rather than legal status. This view is founded on weighty ethical arguments (17). The Norwegian Medical Association, Norwegian Nurses Organisation and eleven other organisations launched an appeal to improve access to health services for undocumented migrants in Norway (18). Earlier this year, the Norwegian parliament rejected a proposal to increase access to primary health services for undocumented migrants and to work up funding arrangements for these services (19). One of the main arguments against the proposal was the fear of health tourism. In these discussions, Minister of Health Bent Høie stated that he did not see a need to consider extending the healthcare rights of migrants without an indefinite leave to remain (20).
Countries move towards the UN’s Sustainable Development Goals on different paths. As other countries take steps towards universal health coverage, Norway should also consider its current strategies. According to the World Health Organisation’s recommendations, universal health coverage is best achieved by gradually increasing access to health services. It is recommended that essential services should be prioritised. When services are provided free of charge, or at a low cost, they will be accessible even to vulnerable groups (21). It is difficult, in theory as well as in practice, to come up with a definition of essential healthcare services. Many may agree that experimental cancer treatments or rehabilitation programmes cannot be considered essential healthcare services, but that treatment for diseases such as diabetes, or the provision of maternity care, is. In discussions about universal health coverage in Norway, it is necessary to clarify which healthcare services should be offered to undocumented migrants. In order to safeguard their fundamental right to the highest attainable standard of health, it is crucial that they are given affordable access to essential health services. Services such as caesarean sections and treatment for pneumonia should therefore, in most cases, be provided free of charge.
The UN’s Sustainable Development Goals and our obligation to protect human rights challenge the practical, legal and financial organisation of healthcare services made available to undocumented migrants in Norway. For Norway to be able to claim that universal health coverage is provided, it is necessary to ensure access to further essential healthcare services for undocumented migrants, and the level of out-of-pocket charges must be reduced.
