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Care for undocumented migrants. A follow-up on the act concerning healthcare for people residing in Sweden without permission (2015:10)

Since 1 July 2013, the county councils have been under the obligation to offer undocumented migrants over the age of 18 with healthcare that cannot be deferred and free healthcare when this is provided pursuant to the Communicable Diseases Act. The county councils are also to offer perinatal care, abortion care, contraceptive advice and a medical examination, if this is not obviously unnecessary. The cost of the care provided is to be subsidised by the county councils. Children under the age of 18 are to be offered healthcare on the same terms as those that apply to children who are residents of the county council. (The Act (2013:407) concerning Healthcare for Certain Aliens Residing in Sweden Without the Necessary Permission and new provisions in the Communicable Disease Act (2004:168).

The Swedish Agency for Public Management's assignment and interim report

The Swedish Government has tasked the Swedish Agency for Public Management (Statskontoret) with analysing how the new regulations have been implemented and applied. A final report on this assignment is to be presented by 15 April 2016, at the latest. This interim report has been restricted to the issues involved in charting:

  • the extent to which undocumented migrants have been offered healthcare,
  • which steps have been taken to ensure that health service staff are aware of the new regulations, and
  • how central government agencies and the county councils have worked to develop the new regulations, guidance and procedures that make it easier for the health service to comply with the new legislation.

The majority are offered care in accordance with the law

Statskontoret's assessment is that the majority of undocumented migrants who seek care are offered it in accordance with the law. We base this assessment on interviews with administrative staff at each of the county councils and on follow-ups conducted by voluntary organisations.

Voluntary organisations have followed up the barriers undocumented migrants have come up against when they have turned to the publicly funded health service. The most common barriers are that health service staff have lacked knowledge about the content of the new act. It is also relatively common that barriers arise due to inadequate procedures, for example that prescriptions have been formulated incorrectly or that problems have arisen with booking appointments.

Demand for care overestimated ahead of the reform

The county councils registered 19 000 visits in 2014, with the care offered to undocumented migrants costing just over SEK 100 million. This care was concentrated in the major city regions. Stockholm County Council accounted for about half of the reported costs.

The compensation the county councils received for their expanded care commitment was three times higher than the reported cost in 2014. Although there is a significant shortfall in the reporting, the county councils have been seriously overcompensated for their expended commitment. Stockholm County Council's costs for 2014 were equivalent to about 80 per cent of the financial compensation, while the other county council's costs were on average only 20 per cent of the compensation.

Statskontoret's assessment is that it is too early for the Government to review the compensation the county councils receive. Healthcare costs have increased continuously since the law came into force, which means that more undocumented migrants have received care. It is likely that these costs will continue to rise as a result of the legislation becoming more widely known, both among undocumented migrants and among health service staff.

Knowledge of the new regulations among health service staff can be improved

Each of the county councils implemented information initiatives in conjunction with the introduction of the legislation. Since then, only a few county councils have implemented new initiatives to provide information about the new regulations. Statskontoret's assessment is that the county councils need to make more of an effort to inform health service staff about the access to healthcare which should be enjoyed by undocumented migrants. The county councils also need to review their guidelines and guidance that describe the significance of the legislation. For example, Statskontoret has seen guidance documents that describe the significance of the legislation in an incorrect way.

The county councils need to develop procedures

Statskontoret's assessment is that many county councils need to develop guidance and procedures that describe how the care offered to undocumented migrants is to be delivered. The existing documentation is rarely complete. However, there are county councils that have produced information that can function as examples of good practice. For example, Stockholm County Council published a handbook that provides guidance on the majority of questions that may arise when undocumented migrants seek care.

Guidance needed about EU citizens' right to subsidised care

EU citizens have a relatively far-reaching right to reside in Sweden and are normally not covered by the new legislation. However, according to the preliminary work on the Act, this does not preclude the Act becoming applicable to EU citizens in isolated cases. What the requirements are for EU citizens to be covered by the Act is not described in more detail.

Statskontoret can conclude that the county councils make different assessments of when EU citizens are to be considered undocumented migrants and gain access to subsidised care. According to the information received, some county councils essentially always charge for the care offered to EU citizens. Other county councils regard EU citizens who have resided in Sweden for longer than is permitted as undocumented migrants. There are also county councils who take into account whether the person seeking care has the opportunity to utilise the health insurance provided by their country of origin when assessing whether to regard them as an undocumented migrant.

Statskontoret concludes that there are big differences between these ways of interpreting the legislation. The question of whether EU citizens are to have access to subsidised care in Sweden is a fundamentally important question that should be interpreted consistently within the health service. Accordingly, Statskontoret believes that the Government should assign the National Board of Health and Welfare the task of drawing up guidance in how the law is to be interpreted in consultation with the agencies affected.

The conditions for safe care need to be improved

The new act means that undocumented migrants are to have the opportunity to receive care without needing to prove their identity. This makes it difficult for the health service to comply with the patient safety requirements regulated in other legislation. As undocumented migrants do not have personal identity numbers, the county councils use different reserve number systems in order to document the care that has been offered. Some county councils produce a new number at each visit. Other county councils encourage the patient to save their number in case they need to use the health service again.

Statskontoret's assessment is that the care offered to undocumented migrants would become safer if there was a universal reserve number system. This would improve the chances of collecting care data from different county councils. This would probably also make it easier to track an individual's care history if the person has previously been an asylum seeker.

Statskontoret's recommendations

Statskontoret has the following recommendations for the Government:

  • Assign the National Board of Health and Welfare the task of drawing up guidance on when EU citizens can be encompassed by the Act concerning Healthcare for Certain Aliens Residing in Sweden Without the Necessary Permission in consultation with the agencies affected.
  • Assign the National Board of Health and Welfare the task of drawing up a system that better complies with the patient safety requirements than the reserve number system currently used to register care provide to undocumented migrants in consultation with the county councils and the central government agencies affected.

Statskontoret has the following recommendations for the county councils:

  • Draw up a handbook or the equivalent that provides an overall description of how health service staff are to deal with different types of question that may arise in conjunction with undocumented migrants seeking care. 
  • Review and update guidelines and guidance describing who is to receive care in accordance with the new legislation and what care the county council is to offer.

Train staff who come into contact with undocumented migrants about the Act and the target group and ensure that staff have access to accurate and readily available information.