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Indeed, some countries in southern Europe, such as Italy and Portugal, offer better coverage for undocumented migrants than do wealthier countries in central and northern Europe that have longer immigration histories. In 2010, emergency care was effectively inaccessible to undocumented migrants in nine of the 27 EU countries (EU27) and access to health services beyond emergency care (that is, primary and secondary care) was available to undocumented migrants in only four EU Member States, including Portugal (1) (Table 1).

–  –  –

Full access under specified conditions France, Netherlands, Portugal, Spaina, Switzerland In Spain the situation changed in 2012 when a new law limited public coverage for undocumented migrants for emergency a care, pregnancy or births (2).

Source: Björngren Cuadra & Cattacin (4).

Among other issues addressed, resolution WHA61.17 on the health of migrants requested the WHO Director-General to analyse the major challenges to health associated with migration and to explore policy options and approaches for improving the health of migrants. To address these requests, the WHO Regional Office for Europe manages the Public Health Aspects of Migration in Europe (PHAME) project. Within the framework of the project, following repeated, sudden, massive influxes of migrants in several countries of the WHO European Region, the WHO Regional Office for Europe developed a toolkit for assessing health system capacity to manage sudden, massive influxes of migrants.

The tool has been developed in collaboration with the International Centre for Migration Health and Development (ICMHD, a WHO collaborating centre based in Geneva) through a consultative process involving experts from various European countries during the first half of 2013.

The tool was first tested in Sicily, Italy in October 2013. One month later, the WHO Regional Office for Europe, in agreement with the Portuguese Ministry of Health, decided to use the tool in Portugal because of the country’s prominent role in health and migration policies in Europe and to test the usefulness of the tool in a country as yet unaffected by a sudden, massive influx of migrants.


Scope of the mission The mission aims were to: (1) assess the Portuguese health system preparedness for a sudden, massive influx of migrants; and (2) test the usefulness of the tool in a country never previously affected by such events.

Method The assessment methodology implements the WHO toolkit for assessing health system capacity to manage sudden, massive influxes of migrants. It comprises site visits and semi-structured interviews, carried out with key government officials, managers of migrant centres, health staff working in migrant centres and experts of nongovernmental organizations (NGOs). The assessment tool and consequently the interviews are based on the WHO health systems framework, which addresses six key functions: leadership and governance; health care financing; health workforce;

medical products, vaccines and technology; health information; and service delivery.

Site selection Assessment locations were selected based on being sites of migrant centres and/or locations of migrant health services and/or institutions for emergency management.

Constraints The agenda of the mission mostly focused on a series of meetings held in various offices dealing with migration health and on visiting migrant health services located in the capital city, Lisbon (Fig. 1), the centre for unaccompanied minor asylum seekers and the migrant detention centre in Porto, the Directorate-General of Health, the Immigration and Borders Service (SEF), the High Commission for Immigration and Intercultural Dialogue (ACIDI), the International Organization for Migration (IOM), the Portuguese Refugee Council (CPR), the Jesuit Refugee Service (JRS), the Ministry of Internal Affairs, the Maritime Operational Centre and the National Civil Protection Authority (ANPC).

As agreed with the Portuguese authorities, no assessments were conducted in the temporary installation centres (CITs) located at the airports in Faro and Porto and the Bobadela Reception Centre for adult asylum seekers near Lisbon. Similarly, it was not planned within the first assessment to visit the island of Madeira, which could be a site of interest for potential sudden, massive influxes of migrants from North Africa.

–  –  –

Overall findings and recommendations Type of emergency Portugal has never been affected by a sudden, massive influx of migrants, mostly owing to its geographical location.

Indeed, the country is bounded to the west and south by the Atlantic Ocean and to the north and east by Spain. The extensive Portuguese coast line (about 900 km) includes the archipelagos of the Azores and Madeira. However, the Atlantic Ocean is often very rough, and therefore not suitable for navigating small, unsafe vessels such as those usually used to transport influxes of migrants in the Mediterranean Sea. The main entry point to Portugal for migrants is the airport in Lisbon. Few irregular migrants1 enter the country by land or by sea hidden in commercial containers (2).2 However, experience shows how any logistical difficulties can be overcome by the desperate need of migrants to escape from even more difficult situations existing in their native countries or wherever they are living, owing to conflicts or dramatic economic crises. In this context, new migration routes to Europe could be opened and Portugal must be ready to respond to unprecedented migrant events.

Leadership and governance Findings T he Portuguese approach to immigration mostly focuses on acceptance and integration rather than control and expulsion. The integration of migrants into the national community receives sustained political consensus, which remains a guiding principle, regardless of the ruling party or coalition.

Concerning health care, Article 64 of the Portuguese Constitution provides that all residents – including foreign citizens – are entitled to general health care irrespective of their economic, social and cultural conditions.3 In the Constitution, the National Health Service (NHS) is defined as “universal and general and, with particular regard to the economic and social conditions of the citizens who use it, [it] shall tend to be free of charge”.4 All citizens, including regular migrants,5 pay a small fee to access NHS services, excluding children up to 12 years of age, pregnant women, patients with 60% or more disability and patients in a situation of proven economic failure, as well as dependants of their household. Public health services cannot refuse to provide assistance for any reasons related to a person’s nationality, lack of economic means or legal status.

Immigrants without a residence permit, or who find themselves in an irregular situation under the immigration legislation in force, still gain access to the NHS by presenting a document from the civil parish in which they live, certifying that they have been living in Portugal for more than 90 days.

Immigrants that cannot prove residence of longer than 90 days can still access NHS services free of charge in the

following cases:

• urgent and vital health care;

• communicable diseases that pose a danger or threat to public health (tuberculosis or AIDS, for example);

• maternal, reproductive and child health care, including access to family planning consultations, voluntary termination of pregnancy, monitoring and surveillance of women during pregnancy, childbirth and childcare, and health care provided to newborns;

• immunization, according to the national immunization programme in force;

• irregular migrant children up to 12 years old;

• foreign citizens in a family reunification situation, when someone in the household has proven social security contributions;

• patients in a situation of proven economic failure, as well as dependants of their household.

Irregular migration is defined by the IOM as “Movement that takes place outside the regulatory norms of the sending, transit and receiving countries … From the perspective of destination countries it is illegal entry, stay or work in a country, meaning that the migrant does not have the necessary authorization or documents required under immigration regulations to enter, reside or work in a given country”. However, the term “illegal migration” tends to be restricted to cases of smuggling and trafficking of migrants (5).

According to the SEF annual report on immigration, borders and asylum (2), 12 undocumented migrants were found on board various vessels in 2012.

This right is protected by regulation, according to the Administrative Order of the Ministry of Health No. 25360/2001.

Article 64, No. 2 of the Constitution of the Portuguese Republic.

Regular migration is defined by the IOM as “Migration that occurs through recognized, legal channels” (5).


Access to health services is organized through the assignment of a temporary code at first contact with health centres.

According to several members of health staff working in migrant centres interviewed during the mission, the complexity of the administrative procedures and the possibility of having to pay for services limit access to the NHS for many undocumented migrants. A growing body of international literature confirms that immigrants face individual, sociocultural6and administrative barriers when using health services in Portugal (6).

Regarding asylum seekers, Law No. 27/2008 of 30 June 2008 establishes the conditions and procedures for granting asylum or subsidiary protection by transposing into the national legal framework Council Directive 2004/83/EC of 29 April 2004 and Council Directive 2005/85/EC of 1 December 2005. The aforementioned Law No. 27/2008 also provides a simplified legal framework for receiving asylum seekers and specifies the minimum standards for treatment in the reception of asylum seekers and refugees, in particular regarding health care and legal aid.

In essence, asylum can be requested upon arrival to Portuguese territory. Asylum seekers have the right to receive an answer regarding their application within 60 days. In terms of health care, asylum seekers have the same entitlements as Portuguese nationals.

The ACIDI is a public institution established in 2007 by Decree-Law No. 167/2007 of 3 May 2007.6 It falls under the Cabinet of the Prime Minister and carries out a wide range of activities (Fig. 2) to promote and support the welcome and integration of immigrants through interministerial strategies.

–  –  –

The ACIDI has dedicated particular attention to the development, implementation and monitoring of public immigration policies in collaboration with academia and research centres. The ACIDI Immigration Observatory, created in 2003, promotes dialogue between academia and policy-makers relating to the integration of migrants in Portugal.

The institution is responsible for coordinating and monitoring the implementation of the National Plan for Immigrant Integration, agreed with the Presidency of the Council of Ministers. The plan is drafted and revised every three years and consists of a series of interministerial political measures with indicators and goals aimed at the best possible integration of immigrants in Portugal.

Prior to 2007 the work of the ACIDI had been coordinated since 1996 by the High Commission for Immigration and Ethnic Minorities (ACIME).

–  –  –

In 2004 the ACIME created two national immigrant support centres (CNAIs) in Lisbon and Porto, respectively, to propose integrated interventions, in collaboration with representative immigrant associations, social partners, and various public administration agencies and services. The centres have been recognized as so-called one-stop shops for best practice.

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