South to South migration and access to health care: The case of bordering country immigrants in Arge

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South to South migration and access to health
careThe case of bordering country immigrants in
Argentina

• Nina Zamberlin
• CEDES
• Buenos Aires, Argentina

Séminaire Migrations et Développement Plate-form
e pour la Population et le Développement Bruxelles
, 13 Mars 2006
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Migration and health Dimensions for analysis

• Disease transmission or acquisition as a
  consequence of migration
• Health problems that arise from the migrating
  process (stress, lower defenses, life style
  change)
• Differences in patterns of morbidity between
  native and migrant populations
• Health issues as a part of the decision to
  migrate
• Immigrants access to health care
• Institutional responses to immigrants health
  care needs

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Sources for this presentation

• Argentine National Censuses and household surveys
• Bibliography Novick (2004) Cerrutti (2004)
  Caccopardo Maguid (2001) Cenicacelaya (2003)
  Jachimowicz (2003).
• E. Jelin, A. Grimson, M. Cerrutti, and N.
  Zamberlin Regional Migration and health in
  Argentina Citizenship, discrimination and
  intercultural communication (2005)
• Analysis of the conditions affecting access to
  health care by bordering country immigrants in
  Argentina, as well as the intercultural
  situations that take place during. health care
  provision.

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ARGENTINA

• Population 36 million
• Urban population under poverty line 38,5
• Urban population in extreme poverty 13,6
• Unemployment 10,1
• Underemployment 11,9
• Growing social inequities in the 1990s
• Between 1998 and 2003 the poverty incidence
  increased from 26 to 47.8
• 2001 economic collapse and social and
  institutional crisis.
• Sanitary emergency

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Argentina Health care system

• Three sub-sectors public, private and social
  insurance funds (obras sociales)
• Public sector provides free medical care
• Increase of demand in public health care system
  (lower class and former middle class currently
  unemployed)
• Nearly half of the population has only public
  health coverage
• Crisis of the public health care system

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ARGENTINA

• International migration has been key for economic
  development
• European immigrants (late 19th and early 20th
  century)
• 8.5 million immigrants from Spain and Italy
  arrived between 1870 and 1950
• Immigrants from neighboring countries (20th
  century)
• Between 1955 and 1985 1.5 million immigrants from
  neighboring countries settled in Argentina

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ARGENTINA
End of the 20th century changes in immigration
flow. Co-existence of two different trends.

• EMIGRATION
• Skilled young professionals who leave due to
  economic crisis and high unemployment
• Mostly to Europe and US
• 300.000 left to Spain and Italy in past 5 years
• 1.05 million Argentines are were living abroad as
  of March 2005.

• IMMIGRATION
• From neighbouring countries with weaker economies
  whose natives seek employment and higher wages
• Unskilled, low wage mostly in the informal sector
  (agriculture, construction and domestic work).
• MERCOSUR

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Immigrant population 1895-2001
Source Novick, S. Evolución reciente de la
política migratoria Argentina, 2005.
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Immigrant population in Argentina (1869- 2001)
INDEC, Argentine National Censuses
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Bordering country immigrants in national censuses
(1869-2001)
Source INDEC, Argentine National Censuses
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Immigrants in Argentina

• 70 of the immigrant population from bordering
  countries is between ages 25-64
• 25.4 of immigrant population from bordering
  countries never attended school or did not
  complete primary school
• Men Construction work. Women domestic work,
  textile industry (sweatshops)
• Concentrate in marginal urban areas. Precarious
  living conditions
• Low income (exploitation, illegal status, no
  benefits or health insurance)
• Many returned after the 2001 economic crisis
  (devaluation)

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Top eight source countries of immigration as a
of the total foreign-born population
Foreign-born population 1,531,940 (5 of the
total) 66 are immigrants from neighbouring
countries Migration rate 0.4/1,000
population The country is host to over half of
South America's migrant population.
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Bordering country (and Peru) immigrants in
Argentina (2002)
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Reasons for migrating

• Better economic opportunities (Differences in per
  capita income)
• Family
• Age
• Health status (great disparities in access to
  health care differences in morbidity and
  mortality patterns)
• Argentina greater availability of services,
  quality, professional competence, technology.
• Solid public health care system (per capita
  health expenditure)
• 14 of users of the public health care system are
  NC migrants

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Socioeconomic and health indicators
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Immigration legislation

• Videla Law (1981-2003)
• Issued by the military dictatorship
• Based on repressive and discriminatory
  conceptions (Selective immigration)
• Immigrants considered a threat to national
  security and public order
• Emphasis on control and deportation
• No respect for fundamental rights guaranteed by
  the Constitution
• Any public official (including teachers and
  doctors) who had contact with an undocumented
  foreigner had the obligation to report him/her to
  the immigration control authorities.

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Immigration legislation

• New immigration law (2003)
• Significant progress in the recognition of
  immigrants rights.
• Objective Promote the integration in Argentine
  society of those who have been admitted as
  permanent residents
• State must guarantee immigrants equal access to
  the protection and rights that Argentine born
  citizens are entitled to, particularly access to
  social services, health, education, justice,
  employment and social security.
• In no case should access to the right to health,
  social assistance or sanitary care, be denied or
  restricted to any foreigner who requires it
  regardless of his/her immigration status.
• the authorities of health care institutions must
  offer orientation and information about the
  necessary steps to solve the irregular
  immigration status.

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Immigration legislation

• Mercosur Free Movement and Residence Agreement
  (2002)
• Signed also by Bolivia and Chile
• Similar to the EU model of open borders. Grants
  Mercosur citizens an automatic visa and freedom
  to work and live in the country.
• The intention of this agreement was to regularize
  illegal immigrants

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Immigration legislation

• Health Law of the City of Buenos Aires (1999)
• Seeks to guarantee the right to integral
  health.
• Its dispositions are valid within the citys
  territory and reach all persons without
  exception, regardless of whether they are
  residents or non-residents of the City of Buenos
  Aires.
• The rights for all people with regards to their
  relationship with the health care system and
  services include the inexistence of economic,
  cultural, social, religious, racial, sexual,
  ideological, political, ... or any other type of
  discrimination.
• Law 664 (2001) states that access to public
  health care services, education, justice, and
  social services provided by the City of Buenos
  Aires are of non-restrictive character. No
  limitation to their practice could be based on
  reasons of origin, nationality, race, language,
  religion, or immigration or social status.

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Immigration legislation

• Contrary to global trends, recent migration
  policy developments in Argentina are intended to
  create a more open immigration regime.
• Legal framework provides sufficient legal
  protection to ensure that immigrants rights are
  not violated
• However the existence of laws regulating rights
  and obligations of individuals and the State does
  not necessarily imply that they are enforced and
  respected.
• There are provincial and institutional norms that
  contradict the national law
• Public officials and population are unaware of
  the policy changes

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What is really happening?

• Discrimination
• Medical care denied to undocumented immigrants
• Request of national ID card to provide care
• Charge for medical provision in public health
  care system
• AIDS medication denied
• No admission into health programs

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What is really happening?

• Variations among institutions (access, type of
  care provided, waiting time)
• Differences between hospitals and primary care
  centers
• Crisis of health care system affects both natives
  and immigrants
• Paradox

Limited access to health care
Excessive use of health care system by immigrants
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Immigrants and health careProviders views

• Two types of immigrants
• Those who reside in the country. Considered to
  have the same rights as natives.
• Those who migrate exclusively to use the health
  care system (health charters). Seen as a
  deliberate abuse of scarce public resources.
  According to this logic, providing health care to
  a foreigner indefectibly implies that the same
  type of provision is delayed or denied to an
  Argentine citizen.

Is it really possible for health care providers
to make this distinction???
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Immigrants and health careProviders views

• Administrative problems arise when undocumented
  people receive health care
• Providing care to immigrants is considered a
  waste of money
• Embassies from bordering counties do not respond
  the request of payment for services provided to
  their citizens
• Hospital staff adopt the role of border
  protectors (filter out immigrants)
• Act to prevent the health care system from being
  swindled by foreigners
• Overwhelming demand
• Sometimes there are more restrictions for locals
  than for foreigners
• Racist and xenophobic attitudes (fueled by right
  wing sectors)
• Critical health condition in which many
  foreigners arrive that must be solved in a
  context of excessive workload and frequently
  adverse working conditions.

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If it wasnt that we request ID and they do not
have it because most of them are here illegally-
we wouldnt be providing services to Argentines
and this would be a hospital for foreigners. We
proposed the director to make two different lines
and a system of quotas where we could give
priority to Argentines. The director liked the
idea but the social workers began to say that it
would be discriminating and so forth...
Nonsense!! We are not saying that foreigners
shouldnt receive health care we just want to
set priorities. The reality is that they come to
this hospital, maybe they stay in the country for
one of two months, and then they leave.
Meanwhile, the people who live here have to wait
three or four months to be seen by a doctor. So
for not discriminating foreigners we end up
neglecting our own people (Administrative
employee who assigns appointments at a public
hospital in the City of Buenos Aires)
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Immigrants and health care

• Health professionals who become personally
  involved and try to help vulnerable immigrants
• Flexible with bureaucratic norms that could
  restrain immigrants access
• Friendly institutions known in the immigrant
  community
• Private clinics specifically for immigrants

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Stereotyped images of immigrant women

• Paraguayan Peruvian women
• More educated
• Adapt easily
• Demanding
• Aware of their rights
• Confront medical staff
• Astute

• Bolivian women
• Lower education
• Communication problems
• Submissive, quiet
• Enduring
• Greater tolerance to pain
• Domestic violence
• Male domination

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Cultural differences and medical careBolivian
women in Argentina

• Communication barrier (language, terms, ability
  to express themselves)
• Difficulties to describe symptoms (value of
  anamnesis is lost veterinary medicine)
• Difficulties in interpreting and following
  medical instructions
• Demand more time and patience
• Exhausting, annoying and frustrating for
  providers
• Mutual lack of trust

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Cultural differences and medical careBolivian
women in Argentina

• Position for giving birth
• Breastfeeding
• Refuse C-sections
• Refuse blood extractions
• Machismo. Women do not make decisions
• Clothing. Dont like to undress to be examined
• Personal hygiene habits / possibilities

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Immigration

• Progress in legislation
• Recognition of immigrants rights within a
  framework of human rights
• New paradigm multicultural, inclusive,
  integrated society.
• However changes are not reflected in practice
  yet
• Discriminatory practices persist
• Need to change attitudes and practices
• Challenge TO TRANSLATE THE LAW INTO ACTIONS
• Must define the specific policies and procedures
  which will make possible the concretization of
  the contents of the law.